Failure to Implement Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
Staff failed to consistently implement enhanced barrier precautions (EBP) by not wearing gowns during high-contact care activities for two residents with significant care needs. One resident, who was severely cognitively impaired with Alzheimer's disease, dementia, and depression, required total assistance with dressing, toileting, and transfers, and had a cholecystectomy tube. Staff were observed providing care such as transferring, toileting, and cleaning without wearing gowns, despite the resident being on EBP and physician orders specifying monitoring and changing dressings as needed. Nursing assistants stated that gowns were only necessary when caring for the cholecystectomy tube, not during other high-contact activities. Another resident, who was cognitively intact but had a history of stroke, hemiplegia, hemiparesis, and required maximal assistance with dressing and toileting due to a Foley catheter, also did not receive care in accordance with EBP. Staff were observed assisting with dressing, transferring, and bathing the resident without wearing gowns. Interviews with staff revealed a misunderstanding of when gowns were required, with several staff members indicating that gowns were only needed for catheter changes or bag switches, not for other high-contact care activities such as bathing or dressing. Facility policy and CDC guidance both specify that gowns and gloves are required for high-contact care activities under EBP, including dressing, bathing, transferring, hygiene, and device care. The director of nursing confirmed that gowns should be worn during these activities to prevent the spread of infection. However, observations and staff interviews demonstrated that this protocol was not consistently followed, resulting in a failure to ensure appropriate PPE use to prevent the spread of infection among residents on EBP.